DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY. Daniel A. West, MD I HAVE NO RELEVENT RELATIONSHIPS WITH ANY COMPANIES
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1 DISCLOSURE OF RELEVANT RELATIONSHIPS WITH INDUSTRY Daniel A. West, MD I HAVE NO RELEVENT RELATIONSHIPS WITH ANY COMPANIES
2 The most likely diagnosis is: A. Allergic contact dermatitis B. Pemphigus vulgaris C. Psoriasis D. Tinea corporis E. Tinea versicolor
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4 The most likely diagnosis is: A. Allergic contact dermatitis B. Pemphigus vulgaris C. Psoriasis D. Tinea corporis E. Tinea versicolor
5 Epidemiology All races Male = female Peak age of onset years 90% cases before 40 years
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7 Arthritis Variable, but up to 20-40% Types: Asymmetric oligoarticular Symmetric polyarticular DIP Ankylosing spondylitis Arthritis mutilans
8 Type 1 and 2 psoriasis? Henseler and Christophers Type 1 psoriasis (onset age <40 y), and type 2 psoriasis (onset age >40 y) Type 1: increased in first-degree relatives, increased HLA linkage, more severe disease Type 2: sporadic, less familial, less HLA linkage, less severe
9 Infection HIV Triggers Trauma (physical, chemical, electrical, etc) Pregnancy Drugs (b-blockers, lithium, steroid withdrawal, NSAIDS, antimalarials) Smoking
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13 Distractors Pemphigus vulgaris* Allergic contact dermatitis*
14 Tinea corporis* Incorrect Choices Tinea versicolor*
15 The most likely diagnosis is: A. Arterial ulcer B. Lipodermatosclerosis C. Livedoid vasculopathy D. Pyoderma gangrenosum E. Venous stasis ulcer
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17 The most likely diagnosis is: A. Arterial ulcer B. Lipodermatosclerosis C. Livedoid vasculopathy D. Pyoderma gangrenosum E. Venous stasis ulcer
18 Pathergy Pyoderma gangrenosum Satellite purple papules will appear just distal to the edge of the ulcer and eventually ulcerate Painful with violaceous overhanging border Bullous forms 50% patients with underlying disease Inflammatory bowel disease is most common Therapy often difficult
19 Arterial ulcer Distractors Lipodermatosclerosis*
20 Distractors Livedoid vasculopathy* Venous stasis*
21 The most likely diagnosis is: A. Contact dermatitis B. Psoriasis C. Minocycline hyperpigmentation D. Phytophotodermatitis E. Photodrug eruption
22 The most likely diagnosis is:
23 The most likely diagnosis is: A. Contact dermatitis B. Psoriasis C. Minocycline hyperpigmentation D. Phytophotodermatitis E. Photodrug eruption
24 Photodrug eruption Broad types of photodrug eruptions Phototoxic Photoallergic
25 Phototoxic Photodrug eruption Does not require sensitization Resembles exaggerated sunburn Pain > itch Can develop quickly, i.e. within hours Photoallergic Requires sensitization Resembles contact dermatitis Itch > pain Potentially more delayed
26 Phototoxic Oral > topical Photodrug eruption Amiodarone, tetracyclines, quinolones, sulfonamides, NSAIDs, thiazides, psoralens, voriconazole, phenothiazines, hypericin Photoallergic Topical > oral Sunscreens, fragrances, chlorhexidine NSAIDs, phenothiazines, griseofulvin
27 Unique phototoxic reactions Psuedoporphyria Photo-onycholysis Slate-gray hyperpigmentation Phytophotodermatitis
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30 Contact dermatitis* Distractors Psoriasis*
31 Minocycline hyperpigmentation Distractors Phytophotodermatitis
32 The most likely diagnosis is: A. Calciphylaxis B. Erythema induratum C. Erythema nodosum D. Leukocytoclastic vasculitis E. Toxic epidermal necrolysis
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34 The most likely diagnosis is: A. Calciphylaxis B. Erythema induratum C. Erythema nodosum D. Leukocytoclastic vasculitis E. Toxic epidermal necrolysis
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37 Calciphylaxis Rare disorder with high mortality rate Cutaneous ischemia and necrosis secondary to calcification, intimal fibroplasia and thrombosis of pannicular arterioles Commonly affects individuals with end-stage renal failure High levels of serum calcium and phosphate Risk factors include hyperparathyroidism, elevated calcium-phosphate product, diabetes mellitus, female gender, obesity, warfarin use and protein C or S deficiency, liver disease, systemic corticosteroid use Typical clinical presentation: painful ischemic purpura and necrotic ulceration
38 Distractors Erythema induratum Erythema nodosum*
39 Distractors Leukocytoclastic vasculitis Toxic epidermal necrolysis*
40 The most likely diagnosis is: A. Plasma cell balanitis B. Lichen planus C. Lichen sclerosus D. Herpes simplex infection E. Aphthosis
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42 The most likely diagnosis is: A. Plasma cell balanitis B. Lichen planus C. Lichen sclerosus D. Herpes simplex infection E. Aphthosis
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46 Lichen sclerosus Sclerotic and atrophic white patches and plaques with associated erosion or ulceration Occurs in all ages Genitalia most commonly affected Complications: scarring, phimosis, squamous cell carcinoma Pruritus common complaint
47 Plasma cell balanitis Distractors Lichen planus*
48 Distractors Herpes simplex infection*
49 A 48 year old woman presents with several months of a progressive itchy rash that started on the upper torso and spread to the lower torso and extremities including the palms and soles. The most likely diagnosis is: A. Ichthyosis vulgaris B. Lichen planus C. Pityriasis lichenoides D. Pityriasis rosea E. Pityriasis rubra pilaris
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51 A 48 year old woman presents with several months of a progressive itchy rash that started on the upper torso and spread to the lower torso and extremities including the palms and soles. The most likely diagnosis is: A. Ichthyosis vulgaris B. Lichen planus C. Pityriasis lichenoides D. Pityriasis rosea E. Pityriasis rubra pilaris
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56 Pityriasis rubra pilaris Coalescence of orange-red plaques with islands of sparing Cephalocaudad spread Orange-red waxy keratoderma of palms and soles Follicular papules on an erythematous base on dorsal fingers Varying degrees of exfoliation Thickened nail plate with subungual hyperkeratosis
57 Ichthyosis vulgaris* Distractors Lichen planus* Pityriasis lichenoides*
58 Distractors Pityriasis rosea*
59 The most likely diagnosis is: A. Eruptive xanthomas B. Erythema elevatum diutinum C. Lichen amyloidosis D. Lichen planus E. Necrobiosis lipoidica
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61 The most likely diagnosis is: A. Eruptive xanthomas B. Erythema elevatum diutinum C. Lichen amyloidosis D. Lichen planus E. Necrobiosis lipoidica
62 Eruptive xanthomas Erythematous to yellow papules Extensor extremities, buttocks and hands May be accompanied by pruritus or tenderness Occur in setting of primary or secondary hypertriglyceridemia (>3000 to 4000mg/dL) Type I, IV and V hypertriglyceridemias
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66 Distractors Erythema elevatum diutinum Lichen amyloidosis
67 Lichen planus* Distractors Necrobiosis lipoidica*
68 The most likely diagnosis is: A. Arsenical keratoses B. Keratoderma climactericum C. Erythema multiforme D. Punctate keratoderma E. Syphilis
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70 The most likely diagnosis is: A. Arsenical keratoses B. Keratoderma climactericum C. Erythema multiforme D. Punctate keratoderma E. Syphilis
71 Syphilis Chronic infection caused by Treponema pallidum Intermittent disease with primary, secondary and tertiary stages Variety of clinical presentations Secondary syphillis is associated with systemic signs including fever, malaise and adenopathy
72 Syphilis
73 Distractors Arsenical keratoses Keratoderma climactericum
74 Erythema multiforme* Distractors Punctate keratoderma
75 A 65 year-old man presented with this condition. He said it gets worse in the sun. The most likely diagnosis is: A. Allergic contact dermatitis B. Erysipelas C. Lupus erythematosus D. Rosacea E. Seborrheic dermatitis
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77 A 65 year-old man presented with this condition. He said it gets worse in the sun. The most likely diagnosis is: A. Allergic contact dermatitis B. Erysipelas C. Lupus erythematosus D. Rosacea E. Seborrheic dermatitis
78 Rosacea Inflammatory condition of the pilosebaceous unit Exact cause unknown Known triggers UV light Alcohol Spicy food Extremes in temperature Stress
79 Clinical features Rosacea Erythematotelangiectatic (vascular): flushing, erythema, telangiectasia Papulopustular Phymatous: especially rhinophyma Ocular: dry or gritty sensation, blepharitis, conjuntivitis Rosacea fulminans (pyoderma faciale): very severe form
80 Treatement Avoid triggers Metronidazole Azeleic acid Sulfacetamide +/- sulfur Brimonidine Cyclosporine drops (ocular) Tetracyclines Azithromycin Isotretinoin Lasers Rosacea
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83 Distractors Erysipelas Allergic contact dermatitis*
84 Distractors Lupus erythematosus* Seborrheic dermatitis*
85 A. Sarcoidosis B. Leprosy C. Erysipelas D. Tinea E. Urticaria The most likely diagnosis is:
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87 A. Sarcoidosis B. Leprosy C. Erysipelas D. Tinea E. Urticaria The most likely diagnosis is:
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89 Leprosy Chronic, slowly progressive infectious disease caused by Mycobacterium leprae Predilection for peripheral nerves and skin Organism spread via nasal and oral droplets or breaks in skin barrier Affects all races and ages Peak incidences: yrs and yrs Three requirements for spread of disease Contagious person, susceptible person and close intimate contact
90 Leprosy Most common classification scheme used is by Ridley and Joplin (1966) LL: lepromatous leprosy TT: tuberculoid leprosy BB: borderline leprosy (BL, BB, BT) WHO classification (1997) Paucibacillary (single lesion) Paucibacillary (2-5 skin lesions) Multibacillary (more than 5 skin lesions)
91 Cutaneous manifestations: Leprosy Lepromatous leprosy: widespread, symmetric poorly defined erythematous macules, papules and plaques on face, buttocks, lower extremities Leonine facies, saddle nose deformities, bilateral earlobe infiltration, acquired icthyosis Borderline leprosy: asymmetric discrete erythematous plaques with alopecia Tuberculoid leprosy: few well-demarcated erythematous plaques
92 Distractors Sarcoidosis* Erysipelas
93 Distractors Tinea* Urticaria*
94 A 37 year-old woman presents with a 3 year history of painful erosions in the skin folds that heal leaving scars. The most likely diagnosis is: A. Hailey-Hailey disease B. Candidiasis C. Irritant dermatitis D. Lichen simplex chronicus E. Herpes simplex virus infection
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96 A 37 year-old woman presents with a 3 year history painful erosions in the skin folds that heal leaving scars. The most likely diagnosis is: A. Hailey-Hailey disease B. Candidiasis C. Irritant dermatitis D. Lichen simplex chronicus E. Herpes simplex virus infection
97 Hailey-Hailey disease Familial benign chronic pemphigus AD, mutation in ATP2C1 gene, dysfunctional Ca2+ ATPase and intracellular Ca2+ signalling Second and third decade of life Flaccid blisters and erosions of neck and intertriginous areas axillae, groin, inframammary Easily ruptured blisters, macerated crusted erosions, chronic moist vegetative plaques with painful fissures common
98 Distractors Irritant dermatitis* Candidiasis*
99 Distractors Lichen simplex chronicus* Herpes simplex virus Infection*
100 The most likely diagnosis is: A. Tinea versicolor B. Psoriasis C. Parapsoriasis D. Tinea corporis E. Granuloma annulare
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102 The most likely diagnosis is: A. Tinea versicolor B. Psoriasis C. Parapsoriasis D. Tinea corporis E. Granuloma annulare
103 Controversial entity Parapsoriasis Clonal dermatitis transition point between chronic polyclonal dermatitis and mycosis fungoides? 2 types: small plaque, large plaque
104 Small plaque parapsoriasis Parapsoriasis Considered minimal to no chance of evolving to MF Less than 5 cm diameter Round to oval variably pinkish to hyperpigmented patches, thin plaques Digitate variant Large plaque parapsoriasis Considered to have potential for evolution to MF vs just early stage MF Larger than 5 cm diameter Often more irregular Retiform variant
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106 Tinea versicolor* Distractors Psoriasis*
107 Distractors Tinea corporis* Granuloma annulare*
108 The most likely diagnosis is: A. Cutaneous anthrax B. Gonococcemia C. Reactive arthritis D. Sweet syndrome E. Syphilis
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110 The most likely diagnosis is: A. Cutaneous anthrax B. Gonococcemia C. Reactive arthritis D. Sweet syndrome E. Syphilis
111 Gonococcemia Characteristic cutaneous lesions: Scattered papules or pustules (often hemorrhagic) with necrotic centers on distal acral sites Embolic septic vasculitis Acute arthritis-dermatosis syndrome Most common clinical manifestation of gonoccocal bacteremia Fever, joint pain, rash
112 Distractors Reactive arthritis (Reiter s)* Sweet s syndrome*
113 Distractors Syphilis*
114 The most likely diagnosis is: A. Aphthous stomatitis B. Contact dermatitis C. Erythema multiforme D. Paraneoplastic pemphigus E. Squamous cell carcinoma
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116 The most likely diagnosis is: A. Aphthous stomatitis B. Contact dermatitis C. Erythema multiforme D. Paraneoplastic pemphigus E. Squamous cell carcinoma
117 Aphthous stomatitis Oval, shallow, discrete painful ulcers with yellowish base and erythematous halo Commonly involves labial or buccal mucosa Most often heal within 7-10 days Peak prevalence occurs during second decade
118 Distractors Erythema multiforme* Paraneoplastic pemphigus
119 Distractors Squamous cell carcinoma*
120 The most likely diagnosis is: A. Chronic radiation dermatitis B. Coumadin necrosis C. Leukocytoclastic vasculitis D. Squamous cell carcinoma E. Toxic epidermal necrolysis
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122 The most likely diagnosis is: A. Chronic radiation dermatitis B. Coumadin necrosis C. Leukocytoclastic vasculitis D. Squamous cell carcinoma E. Toxic epidermal necrolysis
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124 Coumadin necrosis Develops within 2-5 days of starting warfarin in the absence of heparin especially with loading doses of coumadin Early drop in protein C levels Incidence is higher in women; peak incidence in 6 th and 7 th decades of life
125 Coumadin necrosis Begins as intense pain, with subsequent development of sharply demarcated erythema with overlying hemorrhage and necrosis. Retiform branching purpura seen at periphery of cutaneous lesions Peak incidence in women >50 years of age. Typical in sites with abundant subcutaneous tissue, such as the breasts, hips, buttocks or thighs.
126 Chronic radiation dermatitis* Distractors Leukocytoclastic vasculitis
127 Distractors Squamous cell carcinoma* Toxic epidermal necrolysis*
128 A 60 year old man presents with severely itchy blisters on the elbows, knees and upper back. The most likely diagnosis is: A. Neurotic excoriations B. Erythema elevatum diutinum C. Pemphigoid D. Scabies infestation E. Dermatitis herpetiformis
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130 The most likely diagnosis is: A. Neurotic excoriations B. Erythema elevatum diutinum C. Bullous pemphigoid D. Scabies infestation E. Dermatitis herpetiformis
131 Dermatitis Herpetiformis Cutaneous manifestation of celiac disease and is associated with gluten sensitivity in most cases IgA antiendomysial antibodies are directed against tissue transglutaminase Mean age of onset: 4 th decade of life M>F:2:1
132 Dermatitis Herpetiformis Symmetric distribution: extensor elbows, forearms, nape of neck, back, buttocks and extensor knees Pleomorphic primary lesions: urticarial papules, plaques and vesicles Classic presentation: grouped excoriated papulovesicles on an erythematous base
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134 Distractors Neurotic excoriations Erythema elevatum diutinum
135 Distractors Pemphigoid* Scabies infestation*
136 A 31 year-old female got this eruption shortly after using a topical steroid for a rash. The most likely diagnosis is: A. Perioral dermatitis B. Perleche C. Actinic cheilitis D. Contact dermatitis E. Herpes simplex virus
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138 A 31 year-old female got this eruption shortly after using a topical steroid for a rash. The most likely diagnosis is: A. Perioral dermatitis B. Perleche C. Actinic cheilitis D. Contact dermatitis E. Herpes simplex virus
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140 Perioral dermatitis (AKA periorificial dermatitis) Common in young adult women Cause unknown, but can be triggered by topical steroids Papules, pustules, erythema, scale; primary lesions often monomorphic Commonly spares vermillion border Can be periocular Can have burning, itching Treat similar to rosacea
141 Perleche (angular cheilitis) Distractors Actinic cheilitis
142 Distractors Contact dermatitis* Herpes simplex*
143 Thank You
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